308 lines
14 KiB
Plaintext
308 lines
14 KiB
Plaintext
|
English French Notes Complete/Exclude
|
||
|
|
14. Was Child Permanently And Totally Disabled Before
|
||
|
|
|15. If Child is Between 18 and 23 Years Of Age, Did Child
|
||
|
|
The Age Of 18?
|
||
|
|
| Attend School Last Calendar Year?
|
||
|
|
IIB - FINANCIAL DISCLOSURE
|
||
|
|
You are not required to provide the financial information in this Section. However, current law may require VA to consider your
|
||
|
|
household financial situation to determine your eligibility for enrollment and/or cost-free care of your nonservice-connected
|
||
|
|
(NSC) conditions. If you are 0% SC noncompensable or NSC (and are not an Ex-POW, WWI veteran or VA pensioner) and your
|
||
|
|
annual household income (or combined income net worth) exceeds the established threshold, you must agree to pay VA co-payments
|
||
|
|
for care of your NSC conditions to be eligible for enrollment. See Section III - Consent and Signature
|
||
|
|
YES, I WILL PROVIDE SPECIFIC INCOME AND/OR ASSET INFORMATION TO HAVE ELIGIBILITY FOR CARE DETERMINED. Complete all
|
||
|
|
sections below that apply to you with last calendar year's information. Sign and date the application.
|
||
|
|
NO, I DO NOT WISH TO PROVIDE MY DETAILED FINANCIAL INFORMATION. I understand I will be assigned the appropriate enrollment
|
||
|
|
priority based on nondisclosure of my financial information. By checking NO and signing below, I am agreeing to pay the
|
||
|
|
applicable VA co-payment. Sign and date the application.
|
||
|
|
IIC - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
|
||
|
|
1. What Was Your Gross Annual Income From Employment (wages, bonuses,
|
||
|
|
tips, etc), As Well as Income From Your Farm, Ranch, Property or Business
|
||
|
|
2. List Other Income Amounts (Social Security, compensation, pension,
|
||
|
|
interest, dividends) Exclude Welfare.
|
||
|
|
3. Was Income From Your Farm, Ranch, Property or Business (if yes, refer to page 2, Section IIC of the instructions.)
|
||
|
|
IID - DEDUCTIBLE EXPENSES
|
||
|
|
1. Non-Reimbursed Medical Expenses Paid By You or Your Spouse (payments for doctors, dentists, drugs,
|
||
|
|
Medicare, health insurance, hospital and nursing home)
|
||
|
|
2. Amount You Paid Last Calendar Year For Funeral And Burial Expenses For Deceased Spouse or Dependent
|
||
|
|
Child (also enter spouse or child's information in Section IIA)
|
||
|
|
3. Amount You Paid Last Calendar Year For YOUR College or Vocational Educational Expenses (tutition, books,
|
||
|
|
fees, materials, etc.) Do Not List Your Dependent's Educational Expenses.
|
||
|
|
IIE - NET WORTH
|
||
|
|
1. Cash, Amount In Bank Accounts (checking and savings accounts, certificates of deposit,
|
||
|
|
individual retirement accounts, etc.)
|
||
|
|
2. Market Value Of Land And Buildings MINUS Mortgages And Liens. Do NOT COUNT YOUR
|
||
|
|
PRIMARY HOME. Include value of farm, ranch, or business assets.
|
||
|
|
3. Stocks And Bonds AND Value Of Other Property or Assets (art, rare coins, etc.) MINUS
|
||
|
|
The Amount You Owe On These Items. Exclude household effects and family vehicles.
|
||
|
|
SECTION III
|
||
|
|
CONSENT TO RELEASE INFORMATION
|
||
|
|
my medical records (including information relating to the diagnosis, treatment of other therapy for the conditions of
|
||
|
|
substance abuse, alcoholism or alcohol abuse, sickle cell anemia, or testing for or infection with the human immunodeficiency
|
||
|
|
virus) to the contractor of any health plan contract under which I am apparently eligible for medical care or payment of the
|
||
|
|
expense of care or to any other party against whom liability is asserted. I understand that I may revoke this authorization
|
||
|
|
at any time, except to the extent that action has already been taken in reliance on it. Without my express revocation, this
|
||
|
|
consent will automatically expire when all action arising from VA's claim for reimbursement for my medical care has been
|
||
|
|
completed. I authorize payment of medical benefits to VA for any services for which payment is accepted.
|
||
|
|
SOCIAL SECURITY NUMBER
|
||
|
|
| DATE OF BIRTH
|
||
|
|
SIGNATURE OF PATIENT
|
||
|
|
III - CONSENT AND SIGNATURE
|
||
|
|
ALL APPLICANTS MUST SIGN AND DATE THE APPLICATION FOR HEALTH BENEFITS
|
||
|
|
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are
|
||
|
|
not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the
|
||
|
|
time expended by all individuals who must complete this form will average 20 minutes. This includes the time it will take
|
||
|
|
to read instructions, gather the necessary facts and fill out the form.
|
||
|
|
Privacy Act Information: The VA is asking you to provide the information on this form under Title 38, United States Code,
|
||
|
|
sections 1710, 1712, and 1722 in order for VA to determine your eligibility for medical benefits. The information you supply
|
||
|
|
may be verified through a computer-matching program. VA may disclose the information that you put on the form as permitted by
|
||
|
|
law. VA may make a
|
||
|
|
disclosure for: civil or criminal law enforcement, congressional communications,
|
||
|
|
epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States
|
||
|
|
is a party or has interest, the administration of VA programs and delivery of VA benefits, verification of identity and status,
|
||
|
|
and personnel administration. You do not have to provide the information to VA, but if you don't, we will be unable to
|
||
|
|
process your request and serve your medical needs. Failure to furnish the information will not have any affect on any other
|
||
|
|
benefits to which you may be entitled. If you give VA your Social Security Number, VA will use it to administer your VA
|
||
|
|
benefits, to identify veterans and persons claiming or receiving VA benefits and their records, and for other purposes
|
||
|
|
authorized or required by law.
|
||
|
|
CO-PAYMENT NOTICE: If you are a 0% service-connected noncompensable or a nonservice-connected veteran (and are not an
|
||
|
|
Ex-POW, WWI veteran or VA pensioner) AND your household income (or combined income and net worth) exceeds the established
|
||
|
|
threshold, you may be eligible for enrollment only if you agree to pay VA co-payments for treatment of your NSC conditions.
|
||
|
|
By signing this application you are agreeing to pay the applicable VA co-payment if required by law.
|
||
|
|
I CERTIFY THE FOREGOING STATEMENT(S) ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.
|
||
|
|
SIGN HERE
|
||
|
|
HEALTH SERVICES
|
||
|
|
10-10EZ Application Quick Lookup --
|
||
|
|
At the prompt, you may enter any one of the following:
|
||
|
|
(1) Application ID
|
||
|
|
(2) Web Submission ID
|
||
|
|
Hyphens must appear just as received from
|
||
|
|
the On-Line 1010-EZ application.
|
||
|
|
(3) Applicant Name
|
||
|
|
No space between last and first name.
|
||
|
|
(4) Applicant SSN
|
||
|
|
Must be entered as nnn-nn-nnnn.
|
||
|
|
App #:
|
||
|
|
Web ID:
|
||
|
|
Date Rec'd:
|
||
|
|
Applicant:
|
||
|
|
Vet Type:
|
||
|
|
Vet new to Vista?:
|
||
|
|
Financial Disclosure:
|
||
|
|
Expect copy from vet?:
|
||
|
|
Review start date:
|
||
|
|
Print date:
|
||
|
|
Sign date:
|
||
|
|
File date:
|
||
|
|
Inactivate date:
|
||
|
|
Appt. Requested:
|
||
|
|
e-mail Address:
|
||
|
|
Comments --
|
||
|
|
NEXT-OF-KIN
|
||
|
|
LAST NAME
|
||
|
|
FIRST NAME
|
||
|
|
MIDDLE NAME
|
||
|
|
SUFFIX NAME
|
||
|
|
AMERICAN SAMOA
|
||
|
|
DISTRICT OF COLUMBIA
|
||
|
|
FEDERATED STATES OF MICRONESIA
|
||
|
|
MARSHALL ISLANDS
|
||
|
|
NORTHERN MARIANA ISLANDS
|
||
|
|
PALAU (TRUST TERRITORY)
|
||
|
|
PUERTO RICO
|
||
|
|
VIRGIN ISLANDS
|
||
|
|
APPLICANT STATE
|
||
|
|
WORK PHONE AREA CODE
|
||
|
|
WORK PHONE NUMBER
|
||
|
|
WORK PHONE EXTENSION
|
||
|
|
HOME PHONE AREA CODE
|
||
|
|
HOME PHONE NUMBER
|
||
|
|
EMPLOYER PHONE AREA CODE
|
||
|
|
EMPLOYER PHONE NUMBER
|
||
|
|
EMPLOYER PHONE EXTENSION
|
||
|
|
WIDOW/WIDOWER
|
||
|
|
UNKNOWN/NO PREFERENCE
|
||
|
|
SC 50-100%
|
||
|
|
SC <50%
|
||
|
|
SC 0%
|
||
|
|
PURPLE HEART
|
||
|
|
MIL. RETIREE
|
||
|
|
SOCIAL SECURITY NUMBER
|
||
|
|
DATE OF BIRTH
|
||
|
|
'Accept Field'
|
||
|
|
Printed
|
||
|
|
Signed
|
||
|
|
Filed
|
||
|
|
Inactivated
|
||
|
|
Sorry, that data element cannot be 'Accepted' for 'Filing'.
|
||
|
|
After filing this Application to VistA, use Register a Patient
|
||
|
|
or Patient Enrollment to enter/update data as needed.
|
||
|
|
Sorry, that data element must be 'Accepted' for this Applicant.
|
||
|
|
After filing this Application to VistA, the Registration options
|
||
|
|
can be used to modify data as needed.
|
||
|
|
After filing this Application to VistA, Integrated Billing users
|
||
|
|
can modify the data using the 'Process Insurance Buffer' option.
|
||
|
|
Sorry, that data element has been Updated and must be 'Accepted'
|
||
|
|
for this Applicant.
|
||
|
|
'Accept All'
|
||
|
|
'Clear All'
|
||
|
|
Sorry, the 'Clear All' action cannot be used for this new patient.
|
||
|
|
It is recommended that all data elements be 'Accepted' for 'Filing'.
|
||
|
|
After filing the Application to VistA, the Registration options
|
||
|
|
can be used to modify data.
|
||
|
|
'Reset to New'
|
||
|
|
Application has been Reset to New...
|
||
|
|
Unreviewed
|
||
|
|
'Verify Signature'
|
||
|
|
Previously Signed
|
||
|
|
Applicant signature is verified...
|
||
|
|
Unsigned
|
||
|
|
Previously Filed
|
||
|
|
Previously Inactivated
|
||
|
|
Application has been closed/inactivated...
|
||
|
|
Filing 10-10EZ Data (Appl. #
|
||
|
|
) to VistA
|
||
|
|
10-10EZ data is being filed as a background job.
|
||
|
|
Task #:
|
||
|
|
'Print Data'
|
||
|
|
Data Print queued to background...
|
||
|
|
'Update Field'
|
||
|
|
Sorry...the selected data element cannot be 'Updated'.
|
||
|
|
No punctuation is allowed other than
|
||
|
|
in a hyphenated name.
|
||
|
|
No punctuation or numerics are allowed.
|
||
|
|
AREA CODE
|
||
|
|
Use format nnn-nnnn. Example: 222-1234
|
||
|
|
Use up to 5 digits; no other characters. Example: 12345
|
||
|
|
Use format nnn-nnn-nnn. Example: 222-33-4444
|
||
|
|
Sorry... that SSN is already used by another person
|
||
|
|
in the INCOME PERSON File (#408.13). Try again.
|
||
|
|
SID
|
||
|
|
VISTA AUTOMATION
|
||
|
|
ADDITIONAL CHILD
|
||
|
|
Services Request
|
||
|
|
Submit ID
|
||
|
|
Email Address
|
||
|
|
Version #
|
||
|
|
Veteran To Mail
|
||
|
|
Provide
|
||
|
|
Details
|
||
|
|
Appointment Request
|
||
|
|
APPLICANT LAST NAME
|
||
|
|
APPLICANT FIRST NAME
|
||
|
|
APPLICANT MIDDLE NAME
|
||
|
|
APPLICANT SUFFIX NAME
|
||
|
|
RATED PERCENTAGE
|
||
|
|
RETIRED FROM MILITARY
|
||
|
|
Receipt Confirmation for:
|
||
|
|
Sent from:
|
||
|
|
Site msg #:
|
||
|
|
1010EZ CONFIRMATION for SID
|
||
|
|
GMT Threshold Lookup by Zip Code or City
|
||
|
|
ZIP Code
|
||
|
|
Zip Code is invalid; there is no GMT Threshold associated with this value.
|
||
|
|
Enter the ZIP code [5 - 12 characters] that you wish to select.
|
||
|
|
GMT Thresholds not found for entered ZIP code.
|
||
|
|
GMT Threshold is not available for entered ZIP code.
|
||
|
|
County Name:
|
||
|
|
State:
|
||
|
|
FIPS Code
|
||
|
|
# in Household
|
||
|
|
GMT Threshold
|
||
|
|
EAS MTOVERRIDE
|
||
|
|
Means Test Alert
|
||
|
|
A Means Test is required or needs to be completed.
|
||
|
|
Please perform MEANS TEST or instruct patient
|
||
|
|
to report for Means Test interview.
|
||
|
|
>> A future appointment cannot be made at this time.
|
||
|
|
>> Override Key in Effect.
|
||
|
|
>> This action may not be completed at this time.
|
||
|
|
>> Check-Out ONLY. Do NOT Check-In (CI) a walk-in appointment
|
||
|
|
You will not be able to check-out the appt. if you do so.
|
||
|
|
AUTOMATED MT LETTERS GENERATOR
|
||
|
|
The prior processing date is not available. A default date
|
||
|
|
will be used.
|
||
|
|
Ok to continue?
|
||
|
|
Select new start date:
|
||
|
|
>> The Means Test Letter search has been run for today.
|
||
|
|
Auto MT Letters: This process is already running,
|
||
|
|
This process is already running, please try again later
|
||
|
|
Auto-Letters Search completed:
|
||
|
|
>> Processing date
|
||
|
|
in progress <<
|
||
|
|
Automated Means Test Letter Generator Statistics
|
||
|
|
Beginning Processing Date:
|
||
|
|
Ending Processing Date:
|
||
|
|
-day Letters:
|
||
|
|
Day Letter Totals:
|
||
|
|
AUTO MT LETTER RESULTS -
|
||
|
|
AUTOMATED MT LETTERS
|
||
|
|
Filter letters by Preferred Facility?
|
||
|
|
Enter 'YES' to limit letters to a specific Facility or 'NO' to print all letters
|
||
|
|
No valid processing date could be found for
|
||
|
|
-day letters for
|
||
|
|
Please select another date.
|
||
|
|
To re-print
|
||
|
|
the Search/Processing date of
|
||
|
|
Please note: ALL
|
||
|
|
-day letters for this processing date will print
|
||
|
|
Enter 'YES' to use the
|
||
|
|
date. Enter 'NO' to select a different date.
|
||
|
|
Do you wish to use this date?
|
||
|
|
Select the date for the letters you wish to re-print.
|
||
|
|
Enter re-print date:
|
||
|
|
Select letter type
|
||
|
|
Select the type of letter to re-print
|
||
|
|
EAS MT LETTERS REPRINT
|
||
|
|
Reprint canceled
|
||
|
|
Letters queued, [
|
||
|
|
...Gathering letters to re-print...
|
||
|
|
>> No letters found to reprint for these parameters.
|
||
|
|
Select Patient Letter status entry to reprint
|
||
|
|
The Prohibit flag is set for this patient
|
||
|
|
Patient is deceased
|
||
|
|
Select Processing Date:
|
||
|
|
Select the letter processing date for this patient
|
||
|
|
A Means Test has already been returned by this patient
|
||
|
|
Patient's Means Test is no longer required
|
||
|
|
There are no letters to re-print for this patient
|
||
|
|
Select letter type to re-print
|
||
|
|
EAS MT RERUN SINGLE LETTER
|
||
|
|
Available Processing Dates:
|
||
|
|
ERROUT(1)
|
||
|
|
Unable to generate entry in EAS MT PATIENT STATUS File, #713.1
|
||
|
|
NO LONGER REQUIRED
|
||
|
|
The following issues were reported by the Means Test Letter Search Process:
|
||
|
|
MT LETTERS SEARCH ISSUES -
|
||
|
|
Select the type of letter to print
|
||
|
|
EAS MT LETTERS PRINT JOB
|
||
|
|
Letters canceled!
|
||
|
|
Letters queued! [
|
||
|
|
...Gathering letters to print...Please wait
|
||
|
|
...Printing letters...
|
||
|
|
Letters to print:
|
||
|
|
Letters where the print date has not reached:
|
||
|
|
The following letters were found but not printed for the following reasons:
|
||
|
|
Incomplete/Bad Addr :
|
||
|
|
Deceased :
|
||
|
|
MT Changed:
|
||
|
|
Prohibit flag set:
|
||
|
|
Not a User Enrollee:
|
||
|
|
Not a User Enrollee of this facility:
|
||
|
|
Total Letters Processed:
|
||
|
|
(MT not returned)
|
||
|
|
Print Letter Results
|
||
|
|
STOPPED BY USER
|
||
|
|
4///YES;5///TODAY;7///MT 'OWNED' BY ANOTHER FACILITY;9///NO;12///NO;18///NO
|
||
|
|
MEANS TEST ANNIVERSARY DATE:
|
||
|
|
Dear
|
||
|
|
Mr./Ms.
|
||
|
|
VA Medical Center
|
||
|
|
Enclosure
|
||
|
|
TEST LETTER (DO NOT MAIL!)
|
||
|
|
THIS IS A TEST LETTER STREET ADDRESS
|
||
|
|
#################### #################### ####################
|
||
|
|
#################### #################### ####################
|
||
|
|
#################### #################### ####################
|
||
|
|
#################### #################### ####################
|
||
|
|
#################### #################### ####################
|